Provider Demographics
NPI:1285111872
Name:IACCARINO, PHILLIP
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:IACCARINO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10133 SHERRILL BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37932-3347
Mailing Address - Country:US
Mailing Address - Phone:865-392-2853
Mailing Address - Fax:855-294-0818
Practice Address - Street 1:4000 FOXHOUND DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE HILL
Practice Address - State:PA
Practice Address - Zip Code:19444-1014
Practice Address - Country:US
Practice Address - Phone:215-402-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-26
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
PAPT028504225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0446631Medicaid